There are multiple indexes on the table. There is one that hasn't had a seek, scan or lookup, but has been updated 223,000,000 times. There's another index that only has a few seeks that I was also considering remove just to alleviate overhead.

I'll look into tuning and the snapshot isolation. Thanks Grant. BTW Grant, it was good to see you at PASS. I only managed to catch one of your sessions, but nice to put a face with the name.